Jimmy Carter was the first U.S. president born in a hospital.
That's all I can muster for today! I am doing five days of LC training at the hospital this week and it is, while incredibly fun and educational, surprisingly (for me) draining on both mind and body. After this week is over, and I finish my master's paper, I hope I can get back to posting more. But in the meantime, I thought I would share about Jimmy Carter!
Wednesday, March 31, 2010
Sunday, March 28, 2010
Beautiful birth video!
Gorgeous birth video, done by the mother's sister who is a professional videographer. (Of course I cried - the music in birth videos always makes me cry!)
Mom's birth story with pictures is here.
I just loved this video. Lovely music, beautiful images, calm water birth in a birth center, and check out the size of that baby, too! Score another one for the big babies!
Theo's Birth video from hailey bartholomew on Vimeo.
Mom's birth story with pictures is here.
I just loved this video. Lovely music, beautiful images, calm water birth in a birth center, and check out the size of that baby, too! Score another one for the big babies!
Friday, March 26, 2010
You buy the hospital ticket, you go for the hospital ride, Part 235624
The Feminist Breeder posted a link today to a friend's blog post about an OB and an L&D nurse discussing c-sections on Facebook. The OB said she was up late waiting for a baby to come out, the L&D nurse recommended "Ahhh just cut her, fuk it!" and when called out for this both the OB and the nurse defended each other, with the nurse loading on some extra distaste for "birth plans".
I actually don't think the OB's original comment was so out of line. I've (obliquely) sighed over a long induction on FB, and I have friends in many jobs (including medical ones) who vent a little bit at the end of a long shift or a tough task. It was really the nurse's response(s) that I thought deserved the ire that's being generated.
And as I was scrolling through all of said ire in the comments, I came across a great comment from Navelgazing Midwife that I wanted to repost here in part. She is responding to many of the people asking why the nurse was hating so much on birth plans.
Doctors and nurses HATE birth plans. Have for years. (There are a minute few who accept them.) The reason the nurse said it sets women up for failure is because the hospital system is not equipped to permit/allow/encourage women to have an autonomous labor and birth. The hospital assembly line moves one way - through as much technology as possible. Asking a nurse to attend to a woman "wandering the halls" (as I've heard said many times before) is unfair because she has other patients to take care of, too. If the patient wants intermittent monitoring, wants to get up periodically, wants to eat and drink in labor, wants to push out of the bed, wants to do without an IV... all of these things cramp the hospital and nurse's (and OB's) style, making their jobs much more difficult... AND, in their eyes, opens them up for some serious liability. *We* can say, "Tough caca. They need to do what we want because we're hiring them and it's my birth," but they can be quite persuasive and manipulative, threatening women in the middle of what should be a glorious experience.
I use the phrase, "You buy the hospital ticket, you go for the hospital ride" because if you want a homebirth in the hospital, you will be sorely disappointed (the "set-up for failure" the nurse speaks of). If you want a homebirth, have a homebirth. Otherwise, acknowledge the limitations, choreograph what you can and don't be surprised if your birth doesn't turn out like you envisioned.
The same can be said about doulas; hospitals, nurses and doctors generally despise them. They get in the way of the care provider's directions, they "make" women question the status quo and rock the boat of misogyny and anonymity in the hospital's birthing assembly line. Some dislike doulas so much, they refuse to work with a client who has one -and some hospitals have banned them altogether.
If a woman feels like she's going into battle in the hospital, I would *highly* encourage her to seek out other options (new doc, new hospital, etc.) if at all possible. I do understand that not everyone has that luxury, but many do. I hope they exercise their power of economics to hire someone who respects them.
I will add the caveat that I don't think that hospitals, nurses, and doctors "generally" despise doulas, birth plans, etc. because I have now worked at multiple hospitals and I would say that generally I have been well-received as a doula - the haters have been the exception, not the rule - and I haven't seen much open disdain for birth plans although I could imagine it's taking place behind the scenes.
But apart from that I will say a big YES YES YES to the rest of this. I know I've posted about it before but I just had to do it again, because I've heard a little too much lately about people's basic dignity being disrespected in the hospital and/or by care providers. Some of these people can change and do, some can and don't, some are stuck with their "hospital ticket" and the ride that it entails.
In short: it's hard to fight the tide of people, like the nurse in the post, who put quotes around the words "birth plans", coming at you in the hospital who are used to getting things done their way, who have gotten things done their way with the 15 other women they've worked with this week, and at all of the 2,500 other births they've worked at in their career. If you think you can buck the tide, ask yourself, who has more practice getting births done their way, you or them? And then prepare yourself thoroughly for resistance, because at best you won't need it and more likely, you will.
(My goodness, all my posts lately have been not very positive, have they? I blame the deadline for my master's paper putting me in a negative frame of mind.)
I actually don't think the OB's original comment was so out of line. I've (obliquely) sighed over a long induction on FB, and I have friends in many jobs (including medical ones) who vent a little bit at the end of a long shift or a tough task. It was really the nurse's response(s) that I thought deserved the ire that's being generated.
And as I was scrolling through all of said ire in the comments, I came across a great comment from Navelgazing Midwife that I wanted to repost here in part. She is responding to many of the people asking why the nurse was hating so much on birth plans.
Doctors and nurses HATE birth plans. Have for years. (There are a minute few who accept them.) The reason the nurse said it sets women up for failure is because the hospital system is not equipped to permit/allow/encourage women to have an autonomous labor and birth. The hospital assembly line moves one way - through as much technology as possible. Asking a nurse to attend to a woman "wandering the halls" (as I've heard said many times before) is unfair because she has other patients to take care of, too. If the patient wants intermittent monitoring, wants to get up periodically, wants to eat and drink in labor, wants to push out of the bed, wants to do without an IV... all of these things cramp the hospital and nurse's (and OB's) style, making their jobs much more difficult... AND, in their eyes, opens them up for some serious liability. *We* can say, "Tough caca. They need to do what we want because we're hiring them and it's my birth," but they can be quite persuasive and manipulative, threatening women in the middle of what should be a glorious experience.
I use the phrase, "You buy the hospital ticket, you go for the hospital ride" because if you want a homebirth in the hospital, you will be sorely disappointed (the "set-up for failure" the nurse speaks of). If you want a homebirth, have a homebirth. Otherwise, acknowledge the limitations, choreograph what you can and don't be surprised if your birth doesn't turn out like you envisioned.
The same can be said about doulas; hospitals, nurses and doctors generally despise them. They get in the way of the care provider's directions, they "make" women question the status quo and rock the boat of misogyny and anonymity in the hospital's birthing assembly line. Some dislike doulas so much, they refuse to work with a client who has one -and some hospitals have banned them altogether.
If a woman feels like she's going into battle in the hospital, I would *highly* encourage her to seek out other options (new doc, new hospital, etc.) if at all possible. I do understand that not everyone has that luxury, but many do. I hope they exercise their power of economics to hire someone who respects them.
I will add the caveat that I don't think that hospitals, nurses, and doctors "generally" despise doulas, birth plans, etc. because I have now worked at multiple hospitals and I would say that generally I have been well-received as a doula - the haters have been the exception, not the rule - and I haven't seen much open disdain for birth plans although I could imagine it's taking place behind the scenes.
But apart from that I will say a big YES YES YES to the rest of this. I know I've posted about it before but I just had to do it again, because I've heard a little too much lately about people's basic dignity being disrespected in the hospital and/or by care providers. Some of these people can change and do, some can and don't, some are stuck with their "hospital ticket" and the ride that it entails.
In short: it's hard to fight the tide of people, like the nurse in the post, who put quotes around the words "birth plans", coming at you in the hospital who are used to getting things done their way, who have gotten things done their way with the 15 other women they've worked with this week, and at all of the 2,500 other births they've worked at in their career. If you think you can buck the tide, ask yourself, who has more practice getting births done their way, you or them? And then prepare yourself thoroughly for resistance, because at best you won't need it and more likely, you will.
(My goodness, all my posts lately have been not very positive, have they? I blame the deadline for my master's paper putting me in a negative frame of mind.)
Tuesday, March 23, 2010
Health care reform and looking down the road to the next reform
Am I excited about health care reform? Yes, although after all the back-and-forth and ups and downs, it ended by feeling a bit anticlimactic - stumbling across the finish line in a daze, just glad to have gotten here. Remember when Obama said he wanted it done by last August?
I am hugely frustrated, as many other people are, by ridiculous restrictions on abortion coverage. I'm also seriously disappointed by the lack of coverage for immigrants (and not just undocumented immigrants - there's a 5-year waiting period even for documented immigrants to get on Medicaid). And I just want to tell a little story.
The CenteringPregnancy group I'm co-facilitating right now is Spanish-speaking, so obviously most of the women are fairly recent immigrants from Latin America. The way Medicaid works, at least in this state, is that when you show up for your first prenatal visit you get two months of "presumptive eligibility". That means that Medicaid will let you get two months of care, and after that you have to prove that you're Medicaid eligible to continue to be covered. So the clinic tries to get as much done as possible before the two months is over. After that, you're paying out of pocket until you go into labor, at which time emergency Medicaid kicks in to cover the birth and a short period thereafter.
At last month's Centering visit, one of the participants got a call - during the visit - that her husband had been arrested and was about to be deported. At this month's visit, we found out that he was deported and that she was struggling to support her family. She was worried about having enough money for food for her other children. At the end of the group, she began to cry. And on top of this, she has to deal with the expenses for this pregnancy. She has an ultrasound scheduled but will have to decide whether to try to scrape together the money for it, or skip it altogether.
Worse, if she or any of the other women outside of their Medicaid eligibility need to be admitted to the hospital for some reason, like blood pressure monitoring, they'll end up with the bill from that too, and those bills are just insane. This is the reason we're getting health care reform, and yet we are making it impossible for a significant segment of the population to access.
Acting like undocumented immigrants are somehow leeches on taxpayer funds is a falsehood. Undocumented immigrants DO pay taxes. Many pay income taxes, and nearly all have payroll taxes taken out. And all of them pay sales taxes. They put a staggering amount of money into Social Security that they can currently never hope to see returned to them. Is all of this so terrible that they won't even be allowed to purchase insurance, again using their OWN money, on the insurance exchanges? God forbid they ever be able to receive Medicaid coverage for medical necessities.
And the thing that really gets me about all this is the fact that all of these pregnant, uninsured undocumented women? Their babies will be born American citizens. Medicaid will willingly, automatically cover those babies and any health problems they have (perhaps as a result of inadequate prenatal care?), for the rest of their lives. But we won't take care of their mothers, even during their pregnancies.
Obama says immigration reform is coming next; it can't come soon enough after this health care bill.
I am hugely frustrated, as many other people are, by ridiculous restrictions on abortion coverage. I'm also seriously disappointed by the lack of coverage for immigrants (and not just undocumented immigrants - there's a 5-year waiting period even for documented immigrants to get on Medicaid). And I just want to tell a little story.
The CenteringPregnancy group I'm co-facilitating right now is Spanish-speaking, so obviously most of the women are fairly recent immigrants from Latin America. The way Medicaid works, at least in this state, is that when you show up for your first prenatal visit you get two months of "presumptive eligibility". That means that Medicaid will let you get two months of care, and after that you have to prove that you're Medicaid eligible to continue to be covered. So the clinic tries to get as much done as possible before the two months is over. After that, you're paying out of pocket until you go into labor, at which time emergency Medicaid kicks in to cover the birth and a short period thereafter.
At last month's Centering visit, one of the participants got a call - during the visit - that her husband had been arrested and was about to be deported. At this month's visit, we found out that he was deported and that she was struggling to support her family. She was worried about having enough money for food for her other children. At the end of the group, she began to cry. And on top of this, she has to deal with the expenses for this pregnancy. She has an ultrasound scheduled but will have to decide whether to try to scrape together the money for it, or skip it altogether.
Worse, if she or any of the other women outside of their Medicaid eligibility need to be admitted to the hospital for some reason, like blood pressure monitoring, they'll end up with the bill from that too, and those bills are just insane. This is the reason we're getting health care reform, and yet we are making it impossible for a significant segment of the population to access.
Acting like undocumented immigrants are somehow leeches on taxpayer funds is a falsehood. Undocumented immigrants DO pay taxes. Many pay income taxes, and nearly all have payroll taxes taken out. And all of them pay sales taxes. They put a staggering amount of money into Social Security that they can currently never hope to see returned to them. Is all of this so terrible that they won't even be allowed to purchase insurance, again using their OWN money, on the insurance exchanges? God forbid they ever be able to receive Medicaid coverage for medical necessities.
And the thing that really gets me about all this is the fact that all of these pregnant, uninsured undocumented women? Their babies will be born American citizens. Medicaid will willingly, automatically cover those babies and any health problems they have (perhaps as a result of inadequate prenatal care?), for the rest of their lives. But we won't take care of their mothers, even during their pregnancies.
Obama says immigration reform is coming next; it can't come soon enough after this health care bill.
Monday, March 15, 2010
Breastfeeding & Feminism conference - will you be there?
While we're on the topic of breastfeeding, are any of you out there going to be attending the Breastfeeding and Feminism Symposium next Saturday, March 20th? I'll be there, and I would love to meet up if you'll be there too - let me know!
Sunday, March 14, 2010
A cold wind blows...for breastfeeding!
The next CenteringPregnancy visit that I am co-facilitating is coming up next week. As always, I am really looking forward to it! One of the topics for this week is breastfeeding, and of course I am assigned to run that section. I was talking to the midwife who runs the group for ideas, and she said that in the past she's done a "Red Rover" style game - "Let anyone who's ever breastfed a baby come over", for example, and then ask those women what their experiences were - a fun way to get people talking.
Our room is very small, though, so I suggested "A Cold Wind Blows" using the same concept. In that game, there's a circle of chairs, with one less chair than people. The idea is that I'll say "A cold wind blows for everyone who's ever breastfed a baby" and then everyone who has breastfed has to get up and find a new chair - only one person is left standing. Then they get a question like "How did breastfeeding go?" and you can also ask people who you noticed get up and find a new seat. These women aren't hugely pregnant yet, so I'm hoping it won't be too crazy an idea, but we'll see!
I'm brainstorming ideas for "cold winds". Here are my ideas so far (with their Spanish translations, since this is a Spanish group):
Everyone who has ever:
- Breastfed a baby/Dado pecho a su bebe
If there are enough people who have breastfed, we can follow up with:
- Had pain from breastfeeding/Tenido dolor de dar pecho?
- Breastfed after going back to work/Seguido dando pecho despues de regresar al trabajo?
- Breastfed for a year or more/Dado pecho un año o mas?
- Had problems with making enough milk/Tenido problemas con producir suficiente leche?
- Gotten help for a breastfeeding problem/Recibido ayuda para resolver una problema con la lactancia?
All of these questions can be followed up with questions about what were problems/advantages/solutions, etc.
- Has a sister or friend who breastfed/Tenido una hermana o amiga que le dio pecho a su bebe?
Follow-up question: What did she tell you about breastfeeding/Que le ha dicho sobre dar el pecho? (Following discussion could go a lot of ways depending on response - also a way to elicit conversation about problems if we don't have enough people who breastfed in the group.)
- Is planning to buy a breast pump/Va a comprar una pompa para sacar la leche?
Follow-up question: When are you planning to use it, and for what/Cuando la va a usar, y para que?
- Heard something good about breastfeeding? Heard something bad?
Follow-up question: What did you hear? (More opportunities to talk about both benefits and problems!)
These questions may entail enough running-around time for moderately-pregnant women, and then we can move into just sitting and discussing! But does anybody have other ideas? (Or comments on my Spanish translations, imperfect as I'm sure they are.)
Note: in one randomized controlled trial, women who participated in CenteringPregnancy were significantly more likely to initiate breastfeeding than those who had been assigned to individual care (66.5% vs. 54.6%; odds ratio 1.73, confidence interval: 1.28-2.35). I'm hoping they used "A cold wind blows" in that trial too.
Our room is very small, though, so I suggested "A Cold Wind Blows" using the same concept. In that game, there's a circle of chairs, with one less chair than people. The idea is that I'll say "A cold wind blows for everyone who's ever breastfed a baby" and then everyone who has breastfed has to get up and find a new chair - only one person is left standing. Then they get a question like "How did breastfeeding go?" and you can also ask people who you noticed get up and find a new seat. These women aren't hugely pregnant yet, so I'm hoping it won't be too crazy an idea, but we'll see!
I'm brainstorming ideas for "cold winds". Here are my ideas so far (with their Spanish translations, since this is a Spanish group):
Everyone who has ever:
- Breastfed a baby/Dado pecho a su bebe
If there are enough people who have breastfed, we can follow up with:
- Had pain from breastfeeding/Tenido dolor de dar pecho?
- Breastfed after going back to work/Seguido dando pecho despues de regresar al trabajo?
- Breastfed for a year or more/Dado pecho un año o mas?
- Had problems with making enough milk/Tenido problemas con producir suficiente leche?
- Gotten help for a breastfeeding problem/Recibido ayuda para resolver una problema con la lactancia?
All of these questions can be followed up with questions about what were problems/advantages/solutions, etc.
- Has a sister or friend who breastfed/Tenido una hermana o amiga que le dio pecho a su bebe?
Follow-up question: What did she tell you about breastfeeding/Que le ha dicho sobre dar el pecho? (Following discussion could go a lot of ways depending on response - also a way to elicit conversation about problems if we don't have enough people who breastfed in the group.)
- Is planning to buy a breast pump/Va a comprar una pompa para sacar la leche?
Follow-up question: When are you planning to use it, and for what/Cuando la va a usar, y para que?
- Heard something good about breastfeeding? Heard something bad?
Follow-up question: What did you hear? (More opportunities to talk about both benefits and problems!)
These questions may entail enough running-around time for moderately-pregnant women, and then we can move into just sitting and discussing! But does anybody have other ideas? (Or comments on my Spanish translations, imperfect as I'm sure they are.)
Note: in one randomized controlled trial, women who participated in CenteringPregnancy were significantly more likely to initiate breastfeeding than those who had been assigned to individual care (66.5% vs. 54.6%; odds ratio 1.73, confidence interval: 1.28-2.35). I'm hoping they used "A cold wind blows" in that trial too.
Monday, March 8, 2010
Monday morning reading: Free articles from Breastfeeding Medicine
The journal Breastfeeding Medicine is offering two weeks of free online access to these three new articles, all touching on themes of women's attitudes towards infant feeding and predictors of infant feeding decisions. I found the last one to be the most thought-provoking, because of the finding that "comfort with formula feeding" was so highly predictive of intention. I would love to see more research exploring what that means to women, and how it plays out in infant feeding decisions. If you have a chance to read through these, I'd love to hear your thoughts!
Early Exclusive Breastfeeding and Maternal Attitudes Towards Infant Feeding in a Population of New Mothers in San Francisco, California
Authored By: J.M. Wojcicki, R. Gugig, C. Tran, S. Kathiravan, K. Holbrook, and M.B. Heyman
What Do Pregnant Low-Income Women Say About Breastfeeding?
Authored By: A. Alexander, D. Dowling, and L. Furman
Comfort with the Idea of Formula Feeding Helps Explain Ethnic Disparity in Breastfeeding Intentions Among Expectant First-Time Mothers
Authored By: L.A. Nommsen-Rivers, C.J. Chantry, R.J. Cohen, and K.G. Dewey
Early Exclusive Breastfeeding and Maternal Attitudes Towards Infant Feeding in a Population of New Mothers in San Francisco, California
Authored By: J.M. Wojcicki, R. Gugig, C. Tran, S. Kathiravan, K. Holbrook, and M.B. Heyman
What Do Pregnant Low-Income Women Say About Breastfeeding?
Authored By: A. Alexander, D. Dowling, and L. Furman
Comfort with the Idea of Formula Feeding Helps Explain Ethnic Disparity in Breastfeeding Intentions Among Expectant First-Time Mothers
Authored By: L.A. Nommsen-Rivers, C.J. Chantry, R.J. Cohen, and K.G. Dewey
Monday, March 1, 2010
Is maternal mortality in the U.S. on the rise, or are we just seeing more of it?
The maternal mortality rate in the U.S. has dropped drastically in the past hundred years – from an estimated 850 deaths/100,000 live births in 1900 to 7.2/100,000 in 1982. However, in recent years this trend has reversed itself, and maternal mortality in 2006 stood at 13.3/100,000 live births (Heron et al. 2006). Looking at these numbers, one can make the argument that it is becoming less and less safe to become pregnant in the U.S.
But where are those numbers coming from, and what are they really telling us? First, it is important to examine how data are collected and the changes that have taken place in maternal mortality reporting. Recognizing that maternal deaths have been historically underreported, many U.S. states have begun adding specific questions about pregnancy status on death certificates, meant to better identify deaths that occur in women who have been pregnant at any time in the past year.
Berg et al. (2003) concluded that increased maternal mortality rates from 1991-1997 were attributable to improved reporting:
The increase in the reported pregnancy-related mortality ratio from 1991 through 1997 almost certainly reflects improved ascertainment of pregnancy-related deaths. Beginning in 1991, the Division of Reproductive Health at the Centers for Disease Control and Prevention requested that states send to the Pregnancy Mortality Surveillance System all certificates for deaths occurring during or within 1 year of pregnancy, not just those which were coded as having been caused by pregnancy complications. At that time, the death certificates for 16 states and New York City contained check boxes or questions asking if the decedent had been pregnant at the time of death or within varying lengths of time before death. In addition, during the 1990s, many state health departments began to use computers to link death certificates of women of reproductive age to birth and fetal death certificates. This linkage and the presence of pregnancy check boxes on the death certificates allowed states to identify more deaths with a temporal relationship to pregnancy, from which those that were pregnancy related (ie, also causally related to pregnancy) could be found. This is reflected in the fact that the percent of the death certificates sent by state health departments to the Pregnancy Mortality Surveillance System that were determined, upon review, to be pregnancy related decreased from 97% for the years 1979–1986 7 to 89.9% for 1987–1990 8 to 59.9% for the period of the current report.
Horon (2005) explains the changes in reporting that took place due to changes in the International Classification of Disease definition of maternal mortality:
Changes were made in the classification of maternal deaths between ICD-9 and ICD-10. ICD-9 classified a death as having a maternal cause only if pregnancy was reported as part of the sequence of events leading to death. These deaths are classified as maternal in ICD-10 as well. However, the coding rules for ICD-10, unlike the rules for ICD-9, classify deaths aggravated by pregnancy as maternal deaths. This includes deaths from previously existing diseases and deaths from nonobstetric conditions that developed during pregnancy and were aggravated by physiological effects of pregnancy
All states had transitioned to using ICD-10 codes by 1999.
Hoyert (2007) concluded that increases from 1998 to 1999, and 2002 to 2003, were solely due to changes in coding and improved reporting, respectively:
In the NVSS [National Vital Statistics System], maternal deaths increased with the introduction of the ICD–10 and when the separate pregnancy status question switched from being supplemental information available from some state certificates to an item expected to be included on all state certificates. Maternal mortality rates increased for both of the years when these changes affecting identification of maternal deaths were implemented. Changes with the ICD–10 that resulted in more indirect maternal causes apply more with the increasing use of separate pregnancy questions. Because most states have yet to adopt the standard format of the separate pregnancy question, it is likely that maternal and late maternal death rates in all states will continue to be subject to increases because of the adoption of questions rather than actual increases in maternal mortality. The "pregnancy related mortality rates" using surveillance data increased between 1991 and 1999 (18). The increase in the surveillance data was attributed in large part to improved identification of "pregnancy-related deaths".
These changes in coding and reporting are necessary: more accurate count of pregnancy-related deaths is vital to efforts to combat maternal mortality. However, when looking at maternal mortality trends, keep in mind that these changes in reporting may be affecting our ability to directly examine pregnancy-related mortality trends over the past 15 years.
This is one of the issues being argued in California, which has seen a jump in maternal mortality, to 16.9/100,000 in 2006. This article on the increase presents several perspectives:
In 2007, the U.S. Centers for Disease Control and Prevention reported that the national maternal mortality rate had risen, but experts such as Dr. Jeffrey C. King, who leads a special inquiry into maternal mortality for the American College of Obstetricians and Gynecologists, chalked up the change to better counting of deaths. His opinion hasn’t changed.
“I would be surprised if there was a significant increase of maternal deaths,” said King, who has not seen the California report.
But Shabbir Ahmad, a scientist in California’s Department of Public Health, decided to look closer. He organized academics, state researchers and hospitals to conduct a systematic review of every maternal death in California. It’s the largest state review ever conducted. The group’s initial findings provide the first strong evidence that there is a true increase in deaths – not just the number of reported deaths. ...
The best estimates show that less than 30 percent of the increase is attributable to better reporting on death certificates. Even accounting for these reporting and classification changes, the maternal death rate between 1996 and 2006 has more than doubled, Main said.
Why has California not released their report on the rise maternal mortality so more people can examine the data directly? I wonder if they're still searching for an explanation in the reporting. When I was interning at a county health department last summer, new numbers came in on infant mortality that showed a surprisingly large increase on several measures. One of my fellow interns researched the change and discovered that it was produced by a change in reporting, and that other counties and states had reported the same phenomenon. Another project we were working on showed up with an error in the code that had underreported late preterm birth rates for years. It looks like the best investigatory efforts of public health professionals in California haven't revealed any such explanation, but (giving them the benefit of the doubt that they aren't just trying to suppress really bad numbers) they may still be hoping to explain away some of this data.
The bottom line with all of this is that while reporting changes may make it hard to make definitive statements about maternal mortality trends in the U.S., they are making it easier to make definitive statements about the current status of maternal mortality by revealing previously uncounted deaths. And the picture isn't pretty, most particularly from a health disparities perspective. While white women had an MMR of 9.5/100,000 in 2006, black women had an MMR of 32.7. In the California data, black women had an MMR of 54.9/100,000. If this is the real picture of maternal mortality in the U.S., we have a long, long way to go.
References
Berg, C. J., Chang, J., Callaghan, W. M., & Whitehead, S. J. (2003). Pregnancy-related mortality in the united states, 1991-1997. Obstetrics & Gynecology, 101(2), 289.
Heron, M., Hoyert, D. L., Murphy, S. L., Xu, J., Kochanek, K. D., & Tejada-Vera, B. (2009). Deaths: Final data for 2006. National Vital Statistics Reports : From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 57(14), 1-134.
Horon, I. L. (2005). Underreporting of maternal deaths on death certificates and the magnitude of the problem of maternal mortality. American Journal of Public Health, 95(3), 478.
Hoyert, D. L. (2007). Maternal mortality and related concepts. Vital & Health Statistics.Series 3, Analytical and Epidemiological Studies / [U.S.Dept.of Health and Human Services, Public Health Service, National Center for Health Statistics], (33)(33), 1-13.
But where are those numbers coming from, and what are they really telling us? First, it is important to examine how data are collected and the changes that have taken place in maternal mortality reporting. Recognizing that maternal deaths have been historically underreported, many U.S. states have begun adding specific questions about pregnancy status on death certificates, meant to better identify deaths that occur in women who have been pregnant at any time in the past year.
Berg et al. (2003) concluded that increased maternal mortality rates from 1991-1997 were attributable to improved reporting:
The increase in the reported pregnancy-related mortality ratio from 1991 through 1997 almost certainly reflects improved ascertainment of pregnancy-related deaths. Beginning in 1991, the Division of Reproductive Health at the Centers for Disease Control and Prevention requested that states send to the Pregnancy Mortality Surveillance System all certificates for deaths occurring during or within 1 year of pregnancy, not just those which were coded as having been caused by pregnancy complications. At that time, the death certificates for 16 states and New York City contained check boxes or questions asking if the decedent had been pregnant at the time of death or within varying lengths of time before death. In addition, during the 1990s, many state health departments began to use computers to link death certificates of women of reproductive age to birth and fetal death certificates. This linkage and the presence of pregnancy check boxes on the death certificates allowed states to identify more deaths with a temporal relationship to pregnancy, from which those that were pregnancy related (ie, also causally related to pregnancy) could be found. This is reflected in the fact that the percent of the death certificates sent by state health departments to the Pregnancy Mortality Surveillance System that were determined, upon review, to be pregnancy related decreased from 97% for the years 1979–1986 7 to 89.9% for 1987–1990 8 to 59.9% for the period of the current report.
Horon (2005) explains the changes in reporting that took place due to changes in the International Classification of Disease definition of maternal mortality:
Changes were made in the classification of maternal deaths between ICD-9 and ICD-10. ICD-9 classified a death as having a maternal cause only if pregnancy was reported as part of the sequence of events leading to death. These deaths are classified as maternal in ICD-10 as well. However, the coding rules for ICD-10, unlike the rules for ICD-9, classify deaths aggravated by pregnancy as maternal deaths. This includes deaths from previously existing diseases and deaths from nonobstetric conditions that developed during pregnancy and were aggravated by physiological effects of pregnancy
All states had transitioned to using ICD-10 codes by 1999.
Hoyert (2007) concluded that increases from 1998 to 1999, and 2002 to 2003, were solely due to changes in coding and improved reporting, respectively:
In the NVSS [National Vital Statistics System], maternal deaths increased with the introduction of the ICD–10 and when the separate pregnancy status question switched from being supplemental information available from some state certificates to an item expected to be included on all state certificates. Maternal mortality rates increased for both of the years when these changes affecting identification of maternal deaths were implemented. Changes with the ICD–10 that resulted in more indirect maternal causes apply more with the increasing use of separate pregnancy questions. Because most states have yet to adopt the standard format of the separate pregnancy question, it is likely that maternal and late maternal death rates in all states will continue to be subject to increases because of the adoption of questions rather than actual increases in maternal mortality. The "pregnancy related mortality rates" using surveillance data increased between 1991 and 1999 (18). The increase in the surveillance data was attributed in large part to improved identification of "pregnancy-related deaths".
These changes in coding and reporting are necessary: more accurate count of pregnancy-related deaths is vital to efforts to combat maternal mortality. However, when looking at maternal mortality trends, keep in mind that these changes in reporting may be affecting our ability to directly examine pregnancy-related mortality trends over the past 15 years.
This is one of the issues being argued in California, which has seen a jump in maternal mortality, to 16.9/100,000 in 2006. This article on the increase presents several perspectives:
In 2007, the U.S. Centers for Disease Control and Prevention reported that the national maternal mortality rate had risen, but experts such as Dr. Jeffrey C. King, who leads a special inquiry into maternal mortality for the American College of Obstetricians and Gynecologists, chalked up the change to better counting of deaths. His opinion hasn’t changed.
“I would be surprised if there was a significant increase of maternal deaths,” said King, who has not seen the California report.
But Shabbir Ahmad, a scientist in California’s Department of Public Health, decided to look closer. He organized academics, state researchers and hospitals to conduct a systematic review of every maternal death in California. It’s the largest state review ever conducted. The group’s initial findings provide the first strong evidence that there is a true increase in deaths – not just the number of reported deaths. ...
The best estimates show that less than 30 percent of the increase is attributable to better reporting on death certificates. Even accounting for these reporting and classification changes, the maternal death rate between 1996 and 2006 has more than doubled, Main said.
Why has California not released their report on the rise maternal mortality so more people can examine the data directly? I wonder if they're still searching for an explanation in the reporting. When I was interning at a county health department last summer, new numbers came in on infant mortality that showed a surprisingly large increase on several measures. One of my fellow interns researched the change and discovered that it was produced by a change in reporting, and that other counties and states had reported the same phenomenon. Another project we were working on showed up with an error in the code that had underreported late preterm birth rates for years. It looks like the best investigatory efforts of public health professionals in California haven't revealed any such explanation, but (giving them the benefit of the doubt that they aren't just trying to suppress really bad numbers) they may still be hoping to explain away some of this data.
The bottom line with all of this is that while reporting changes may make it hard to make definitive statements about maternal mortality trends in the U.S., they are making it easier to make definitive statements about the current status of maternal mortality by revealing previously uncounted deaths. And the picture isn't pretty, most particularly from a health disparities perspective. While white women had an MMR of 9.5/100,000 in 2006, black women had an MMR of 32.7. In the California data, black women had an MMR of 54.9/100,000. If this is the real picture of maternal mortality in the U.S., we have a long, long way to go.
References
Berg, C. J., Chang, J., Callaghan, W. M., & Whitehead, S. J. (2003). Pregnancy-related mortality in the united states, 1991-1997. Obstetrics & Gynecology, 101(2), 289.
Heron, M., Hoyert, D. L., Murphy, S. L., Xu, J., Kochanek, K. D., & Tejada-Vera, B. (2009). Deaths: Final data for 2006. National Vital Statistics Reports : From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 57(14), 1-134.
Horon, I. L. (2005). Underreporting of maternal deaths on death certificates and the magnitude of the problem of maternal mortality. American Journal of Public Health, 95(3), 478.
Hoyert, D. L. (2007). Maternal mortality and related concepts. Vital & Health Statistics.Series 3, Analytical and Epidemiological Studies / [U.S.Dept.of Health and Human Services, Public Health Service, National Center for Health Statistics], (33)(33), 1-13.
U.S. midwives in Senegal
Via a blog by DC-based midwifery students about their trip to work with a maternity clinic in Senegal. Fascinating stories and pictures, and a window on to the realities of accessing medical care in developing countries:
We discuss options for getting this baby out now. Recommendation—immediate transfer.
But as I was to learn, the decision to transfer involves three levels of decisions:
* The medical recommendation that a transfer is the only available solution in this situation;
* The family’s agreement on this recommendation—which involves getting a complicated set of approvals from various family members and money with which to pay for the transfer; and
* Access to transfer—collecting money to pay for the ambulance and the ability to get the ambulance here from Ziguinchor
Check out all the entries - a multi-layered look at traditional birthing practices, medical management, and cultural and social factors, from practitioners striving to come with an open mind:
We are not arrogant or neo-colonialist enough to carry ourselves as if we are here to bring our view of midwifery to Africa. We are here to bring our skills and information and assistance to our Sista-midwives and to help the women who are birthing. We teach and learn from each other.
We discuss options for getting this baby out now. Recommendation—immediate transfer.
But as I was to learn, the decision to transfer involves three levels of decisions:
* The medical recommendation that a transfer is the only available solution in this situation;
* The family’s agreement on this recommendation—which involves getting a complicated set of approvals from various family members and money with which to pay for the transfer; and
* Access to transfer—collecting money to pay for the ambulance and the ability to get the ambulance here from Ziguinchor
Check out all the entries - a multi-layered look at traditional birthing practices, medical management, and cultural and social factors, from practitioners striving to come with an open mind:
We are not arrogant or neo-colonialist enough to carry ourselves as if we are here to bring our view of midwifery to Africa. We are here to bring our skills and information and assistance to our Sista-midwives and to help the women who are birthing. We teach and learn from each other.
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